MEDICARE: BOONES CREEK PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	0000002064	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2142795	OTHER		PK

General Provider Information

NPI Number	:	1073940334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOONES CREEK PHARMACY, INC.

Provider Business Mailing Address
First Line	:	4729 N ROAN ST STE 2
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-3733
Country	:	US
Telephone Number	:	423-283-0911
Fax Number	:	423-283-0990

Provider Business Practice Location Address
First Line	:	4729 N ROAN ST
Second Line	:	STE 2
City	:	JOHNSON CITY
State	:	TN
Zip	:	37615-3886
Country	:	US
Telephone Number	:	423-283-0911
Fax Number	:	423-283-0990

Authorized Official
Title or Position	:	OWNER/PIC
Name	:	CADEN COX
Credential	:	PHARMD
Telephone Number	:	423-283-0911

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	04/28/2026

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